Provider Demographics
NPI:1700140712
Name:LAOTHAVORN, JUNTIRA (MD)
Entity Type:Individual
Prefix:DR
First Name:JUNTIRA
Middle Name:
Last Name:LAOTHAVORN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88 N AVONDALE RD # 181
Mailing Address - Street 2:
Mailing Address - City:AVONDALE ESTATES
Mailing Address - State:GA
Mailing Address - Zip Code:30002-1323
Mailing Address - Country:US
Mailing Address - Phone:404-579-4544
Mailing Address - Fax:
Practice Address - Street 1:1745 PHOENIX BLVD STE 240
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30349-5534
Practice Address - Country:US
Practice Address - Phone:404-507-7100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-25
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1250613542084P0800X
GA0762792084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty